Introduction
Medical workflow is defined as task, process and medical staff working together in a specialized multidisciplinary team to deliver proper healthcare and achieve patient satisfaction with ...good patient experience such as in neuro-oncology centers which deal with central nervous system tumors. The aim of this article is to review workflow of a neuro-oncology center focusing on how to maintain patient satisfaction with the best health care outcome.
Main body
An organized workflow system in a neuro-oncology center is based on a multidisciplinary team of specialized and experienced neurosurgeons, pediatric oncologist, neuroradiologist, neuropathologist and radiotherapy oncologist where the patient is assigned to a primary oncologist and the decision regarding the surgical intervention is decided first by the pediatric neurosurgeon. The optimum workflow in a high flow neuro-oncology center starts with screening of all the referred cases to select those who match the mission and resources of the center to avoid overloading that affects the time and quality for care giving. Admission protocols must differentiate between elective and emergent admissions, centralization of caseload and proper scheduling of operations and outpatient visits. Clinical documentation is mandatory, and the efficiency and effectiveness of electronic health records (EHR) allows for tracing the work and tasks, proper coordination between multidisciplinary teams and generation of national cancer registries. Surgical intervention is followed by chemotherapy and/or radiotherapy according to pre-planned protocols for every specific pathology that is diagnosed by the neuropathologist. As the management of many neuro-oncology cases is complex and may require individualization, multidisciplinary team meetings involving extensive discussions are analysis for the best management plan.
Conclusion
A high flow neuro-oncology center requires a well-planned, and organized multidisciplinary team maintaining workflow system to improve the health outcome, and patient’s compliance and experience.
Objective:Postoperative delirium is the worst patient outcome. Elderly patients undergoing orthopaedic procedures under general anaes- thesia are highly liable to experience delirium. Several studies ...supported melatonin use for the prevention of delirium. This work evaluated the prophylactic efficiency of melatonin for postoperative delirium in patients with multifactorial risk for developing delirium as elderly undergoing orthopaedic trauma surgery under general anaesthesia.Methods:This double-blinded prospective randomized comparative study was conducted on 80 elderly patients subjected to orthopaedic interventions under general anaesthesia. Patients were randomized into group M (Melatonin group) and group NM (Non-melatonin group). Group M received 5 mg melatonin while group NM received placebo. The study drugs were given preoperatively and for the first 3 postop- erative days. For the incidence of delirium, patients were evaluated using the Abbreviated Mental Test. The Pain Assessment in Advanced Dementia, sedation scores, and changes in hemodynamics were recorded.Results:The incidence of delirium was significantly lower postoperatively in M group (25%) relative to NM group (52.5%) (P < .001, OR=2.3. 95% CI=−0.44,+1.23). Abbreviated Mental Test scores at postanaesthesia care unit and day 0 showed a highly significant dif- ferences. However, Abbreviated Mental Test scores had no significant difference within the 3 postoperative days. Heart rate was significantly lower in M group after 50 minutes from the start of surgery. Mean blood pressure, Pain Assessment in Advanced Dementia, and sedation scores showed insignificant differences.Conclusion:Perioperative melatonin treatment could reduce the incidence of postoperative delirium in the studied population, and it could be considered a prophylactic medication.
Background
The indications of transcranial approaches for pituitary adenomas have declined in the last decades with the widespread performance of endoscopic transsphenoidal approaches.
The aim of the ...study was to review the current indications of transcranial approaches for pituitary adenomas and to evaluate the clinical and radiological outcome following these approaches.
Patients and methods
This study included 16 patients with fresh, residual, or recurrent pituitary adenomas operated upon by transcranial approaches alone or in combination with transsphenoidal approaches. The indication to perform a transcranial approach was reviewed for each patient. Postoperative clinical outcome and the extent of tumor resection were assessed.
Results
The indications of transcranial approaches were significant parasellar and/or anterior fossa extensions in 6 patients, failed previous transsphenoidal surgery in 3 patients, giant adenoma extending into the third ventricle in 3 patients, dumbbell-shaped adenoma in 2 patients, and doubtful diagnosis in 2 patients. Two patients with invasive giant adenomas were operated upon by a combined approach. There was a single mortality. Permanent complications included visual loss in one patient, third nerve palsy in one patient, hypopituitarism in two patients, and permanent diabetes insipidus in two patients. Gross total resection was achieved in one patient, subtotal resection in seven patients, and partial resection in eight patients.
Conclusion
Transcranial approaches are still needed for some complex pituitary adenomas particularly giant tumors with significant lateral, anterior, or superior extensions, tumors with fibrous consistency particularly after failure of transsphenoidal approach, and dumbbell-shaped tumors with severe constriction at the diaphragm.
Background
Nonsyndromic anterior plagiocephaly is one of the most common types of craniosynostosis. Different surgical techniques to correct this deformity have been developed with dissatisfaction ...among many surgeons. In this study, we describe a novel surgical technique to manage this pathology
.
The inclusion criteria were patients presenting with non-syndromic anterior plagiocephaly below 1 year of age presenting to the Pediatric Hospital in the period between 2016 and 2019. Surgical time, blood loss, and complications were recorded. The follow-up period was at least 1 year postoperative, and cosmetic outcome satisfactory categories were reported.
Results
Seven patients were included in this study. No intraoperative complications were reported, and no blood replacement was needed in any of the patients. The parents of six patients were completely satisfied (85.7%) with the outcome and partially satisfied in 1 patient (14.3%).
Conclusion
The results of the described rotational overlapping flap technique are promising and can be considered one of the minimally invasive techniques for the correction of this pathology.
Purpose
To analyze the impact of increasing the extent of resection (EOR) on the survival rates and on the surgical outcome of children with medulloblastoma.
Methods
A series of consecutive 405 ...children operated for medulloblastoma between July 2007 and April 2018 was identified. The details of pre-operative data, surgical interventions, post-operative complications, and survival rates were analyzed.
Results
The Kaplan-Meier (KM) analysis showed no advantage of gross total resection (GTR) over near and subtotal resection regarding over all (OS) (
p
=0.557) and progression free survival (PFS) (
p
=0.146). In the same time, increasing the EOR was not associated with higher morbidity. Tumor dissemination at onset correlated to worse OS (KM:
p
=0.003, OR 1.999, 95% CI: 1.242–3.127;
p
= 0.004) and PFS (KM:
p
<0.001, Cox: OR 2.171, 95% CI: 1.406–3.353;
p
<0.001). OS was significantly affected in patients < 3 years old (KM:
p
=0.011, OR 2.036, 95% CI: 1.229–3.374;
p
= 0.006), while PFS was worse among patients who had pre-op seizures (KM:
p
=0.036, Cox: OR 2.852, 95% CI: 1.046–7.773;
p
=0.041) or post-op pseudomeningocele (KM:
p
=0.021, Cox: OR 2.311, 95% CI: 1.123–4.754;
p
=0.023).
Conclusions
Although surgical excision of medulloblastoma is the standard of care, there was no significant benefit for GTR over near or subtotal resection on the OS or PFS rates that are mainly influenced by the patient’s age and tumor dissemination. However, GTR should be targeted, as it is not associated with increased incidence of mutism or other surgery-related complications.
Purpose
This study was designed to present our experience and recommendations regarding the management of pediatric brainstem and peduncular low-grade gliomas (LGGs).
Methods
Retrospective analysis ...was performed for pathologically proven brainstem or cerebellar peduncular LGGs in patients admitted between 2014 and 2019. These lesions were classified into the dorsal exophytic, focal brainstem, cervicomedullary, lower peduncular, and upper peduncular groups, and this classification was the basis for the surgical approach for the lesions.
Results
Sixty-two pediatric patients were included, and their distribution among the aforementioned groups were as follows: 12, 12, 3, 16, and 19 cases in the dorsal exophytic, focal brainstem, cervicomedullary, upper peduncular, and lower peduncular groups, respectively. Stereotactic biopsy was performed for all cases in the focal brainstem group, whereas other groups underwent open excision. Gross total resection (GTR) was achieved in 20 cases (40%), near-total resection (NTR) was achieved in 17 cases (34%), and subtotal resection (STR) was achieved in 13 cases (26%). The extent of GTR and NTR for the upper peduncular, lower peduncular, dorsal exophytic, and cervicomedullary groups were 81.2%, 68.4%,75%, and 66.6%, respectively. Then, 32 cases received chemotherapy. The 3- and 5-year progression-free survival rates were 95% (95% confidence interval (CI) 89.5–100%) and 90.3% (95% CI 79.9–100%), respectively. A significant difference in the 3-year progression-free survival rate was observed between the GTR and NTR groups (
p
= 0.06; 100% vs. 88.2% (95% CI 72.9–100%)).
Conclusion
Surgery plays a definitive curative role in grossly resected cases. Additionally, the role of surgical debulking should be considered, even if GTR is impossible. Meanwhile, chemotherapy showed a beneficial role in patients with focal brainstem lesions and progressive lesions, those with STR, and some patients with NTR.
To assess the clinical, pathological and molecular characteristics (Sonic hedgehog and group 3/4 molecular subtypes expression) and treatment modalities for infantile medulloblastoma in correlation ...with outcomes.
A retrospective study of 86 medulloblastoma patients (≤3 years) was conducted. M0 patients <2.5 years received four cycles of chemotherapy followed by focal radiotherapy (FRT) and chemotherapy. Between 2007 and 2015, Metastatic patients <2.5 years received craniospinal irradiation (CSI) after the end of chemotherapy. After 2015, metastatic patients <2.5 years received CSI postinduction.
The hazard ratio for death was significantly higher in the FRT (HR = 2.8) group compared with the CSI group (hazard ratio = 1). Metastatic disease significantly affected the overall survival of the Sonic hedgehog group and the overall survival and event-free survival of group 3/4.
Metastatic disease had a significant impact on outcomes. FRT is not effective in treating infantile medulloblastoma.
BACKGROUND: One of the most common causes of spinal cord dysfunction is cervical spondylotic myelopathy (CSM) especially in the elderly. Prognostic indices can aid the surgeon preoperatively to ...detect the patients’ prognosis.
AIM: The aim of the work is to better assess patients and to find possible indicators for post-operative improvement or deterioration in CSM patients.
METHODS: Forty patients with multiple levels CSM, admitted and operated on in the Neurosurgery Department of Cairo University Hospitals, have been enrolled randomly in this study after fulfilling the criteria for CSM surgical intervention. The patient age, complaint duration, number of levels affected, signal intensity on T1-weighted and T2-weighted magnetic resonance (MR) images, Japan Orthopedic Association (JOA) scoring system, and Nurick’s score were evaluated before surgery and correlated with outcome after 1 year follow-up.
RESULTS: About 80% of patients improved after operation with average pre- and post-operative JOA and Nurick scores about 11.23 and 3.12; 14.1 and 1.6, respectively. Patient age, sex, number of levels affected, and signal intensity on T1- weighted and T2-weighted MR images were not significantly associated with post-operative improvement, p > 0.05. However, the only significant prognostic factor was the duration of symptoms if less than 1 year with p < 0.05.
CONCLUSION: Short complaint duration coupled with close intra-operative monitoring was directly correlated with good CMS operation outcome while age, sex, number of levels affected, presence of cord signal on MR imaging, and surgical approach appear to have no significant effect on outcome.
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